Journal of Gastrointestinal Surgery

, Volume 17, Issue 1, pp 14–20 | Cite as

Gastroesophageal Reflux Disease and Antireflux Surgery—What Is the Proper Preoperative Work-up?

  • Brian Bello
  • Marco Zoccali
  • Roberto Gullo
  • Marco E. Allaix
  • Fernando A. Herbella
  • Arunas Gasparaitis
  • Marco G. Patti
2012 SSAT Plenary Presentation

Abstract

Background

Many surgeons feel comfortable performing antireflux surgery (ARS) on the basis of symptomatic evaluation, endoscopy, and barium esophagography. While esophageal manometry is often obtained to assess esophageal peristalsis, pH monitoring is rarely considered necessary to confirm the diagnosis of gastroesophageal reflux disease (GERD).

Aims

The aim of this study was to analyze the sensitivity and specificity of symptoms, endoscopy, barium esophagography, and manometry as compared to pH monitoring in the preoperative evaluation of patients for ARS.

Patients and Methods

One hundred and thirty-eight patients were referred for ARS with a diagnosis of GERD based on symptoms, endoscopy, and/or barium esophagography. Barium esophagography, esophageal manometry, and ambulatory 24-h pH monitoring were performed preoperatively in every patient.

Results

Four patients were found to have achalasia and were excluded from the analysis. Based on the presence or absence of gastroesophageal reflux on pH monitoring, the remaining 134 patients were divided into two groups: GERD+ (n = 78, 58 %) and GERD− (n = 56, 42 %). The groups were compared with respect to the incidence of symptoms, presence of reflux and hiatal hernia on esophagogram, endoscopic findings, and esophageal motility. There was no difference in the incidence of symptoms between the two groups. Within the GERD+ group, 37 patients (47 %) had reflux at the esophagogram and 41 (53 %) had no reflux. Among the GERD− patients, 17 (30 %) had reflux and 39 (70 %) had no reflux. A hiatal hernia was present in 40 and 32 % of patients, respectively. Esophagitis was found at endoscopy in 16 % of GERD+ patients and in 20 % of GERD− patients. Esophageal manometry showed no difference in the pressure of the lower esophageal sphincter or quality of peristalsis between the two groups.

Conclusions

The results of this study showed that (a) symptoms were unreliable in diagnosing GERD, (b) the presence of reflux or hiatal hernia on esophagogram did not correlate with reflux on pH monitoring, (c) esophagitis on endoscopy had low sensitivity and specificity, and (d) manometry was mostly useful for positioning the pH probe and rule out achalasia. Ambulatory 24-h pH monitoring should be routinely performed in the preoperative work-up of patients suspected of having GERD in order to avoid unnecessary ARS.

Keywords

Gastroesophageal reflux disease Laparoscopic antireflux surgery Endoscopy Barium esophagography Esophageal manometry Ambulatory 24-h pH monitoring 

Notes

References

  1. 1.
    Dent J, El Serag HB, Wallander MA, Johansson S. Epidemiology of gastro-oesophageal reflux disease: a systematic review. Gut 2005;54:710–717.PubMedCrossRefGoogle Scholar
  2. 2.
    Campos GM, Peters JH, DeMeester TR, Oberg S, Crookes PF, Tan S, DeMeester SR, Hagen J, Bremner CG. Multivariate analysis of factors predicting outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 1999;3:292–300.PubMedCrossRefGoogle Scholar
  3. 3.
    Waring JP, Hunter JG, Oddsdottir M, Wo J, Katz E. The preoperative evaluation of patients considered for laparoscopic surgery. Am J Gastroenterol 1995;90:35–38.PubMedGoogle Scholar
  4. 4.
    Khajanchee YS, Hong D, Hansen PD, Swanstrom LL. Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results. Am J Surg 2004;187:599–603.PubMedCrossRefGoogle Scholar
  5. 5.
    Armstrong D, Monnier P, Nicolet M, Blum Al, Savary M. The “MUSE” system. In: R. Giuli, GNJ Tyagt, TR DeMeester, JP Galmiche (eds) The Esophageal mucosa. New York, Elsevier, 1994.Google Scholar
  6. 6.
    Jamieson JR, Stein HJ, DeMeester TR, Bonavina L, Schwizer W, Hinder RA, Albertucci M. Ambulatory 24-h esophageal pH monitoring: normal values, optimal thresholds, specificity, sensitivity and reproducibility. Am J Gastroenterol 1992;87:1102–1111.PubMedGoogle Scholar
  7. 7.
    Patti MG, Arcerito M, Tong J, de Pinto M, de Bellis M, Wang A, Feo CV, Mulvhill SJ, Way LW. Importance of preoperative and postoperative pH monitoring in patients with esophageal achalasia. J Gastrointest Surg 1997;1:505–510.PubMedCrossRefGoogle Scholar
  8. 8.
    Patti MG, Diener U, Tamburini A, Molena D, Way LW. Role of esophageal function tests in the diagnosis of gastroesophageal reflux disease. Dig Dis Sci 2001;46:597–602.PubMedCrossRefGoogle Scholar
  9. 9.
    Csendes A, Rencoret G, Beltran M, Smok G, Henriquez A. Relationship between gastroesophageal reflux symptoms and 24 h esophageal pH measurements in patients with normal or minimally abnormal upper endoscopies. Rev Med Chil 2004;132:19–25.PubMedGoogle Scholar
  10. 10.
    Chan K, Liu G, Miller L, Ma C, Xu W, Schlachia CM, Darling G. Lack of correlation between a self-administered subjective GERD questionnaire and pathologic GERD diagnosed by esophageal pH monitoring. J Gastrointest Surg 2010;14:427–436.PubMedCrossRefGoogle Scholar
  11. 11.
    Fisichella PM, Raz D, Palazzo F, Niponmick I, Patti MG. Clinical, radiological, and manometric profile in 145 patients with untreated achalasia. World J Surg 2008;32:1974–1979.PubMedCrossRefGoogle Scholar
  12. 12.
    Streets CG, DeMeester TR. Ambulatory 24-hour pH monitoring: why, when, and what to do. J Clin Gastroenterol 2003;37:14–22.PubMedCrossRefGoogle Scholar
  13. 13.
    Ott DJ. Gastroesophageal reflux. What is the role of barium studies? Am J Roentgenol 1994;162:627–629.Google Scholar
  14. 14.
    Chen MY, Ott DJ, Sinclair JW, Wu WC, Gelfand DW. Gastroesophageal reflux disease: correlation of esophageal pH testing and radiographic findings. Radiology 1992;185:483–486.PubMedGoogle Scholar
  15. 15.
    Johnson F, Joelsson B, Gudmundsson K, Greiff L. Symptoms and endoscopic findings in the diagnosis of gastroesophageal reflux disease. Scan J Gastroenterol 1987;22:714–718.CrossRefGoogle Scholar
  16. 16.
    Richter JE. Typical and atypical presentation s of gastroesophageal reflux disease. The role of esophageal testing in diagnosis and management. Gastroenterol Clin North Am 1996;25:75–102.PubMedCrossRefGoogle Scholar
  17. 17.
    Amano Y, Ishimura N, Furuta K, Okita K, Masaharu M, Azumi T, Ose T, Kshino K, Ishihara S, Adachi K, Kinoshita Y. Interobserver agreement on classifying endoscopic diagnoses of nonerosive esophagitis. Endoscopy2006;38:1032–1035.PubMedCrossRefGoogle Scholar
  18. 18.
    Bytzer P, Havelund T, Moller Hansen J. Interobserver variation in the endoscopic diagnosis of reflux esophagitis. Scan J Gastroenterol 1993;28:119–125.CrossRefGoogle Scholar
  19. 19.
    Patti MG, Arcerito M, Feo CV, De Pinto M, Tong J, Gantert W, Tyrrell D, Way LW. An analysis of operations for gastroesophageal reflux disease. Identifying the important technical elements. Arch Surg 1998;133:600–607.PubMedCrossRefGoogle Scholar
  20. 20.
    Horvath KD, Jobe BA, Herron Dm, Swanstrom LL. Laparoscopic Toupet fundoplication is an inadequate procedure for patients with severe reflux disease. J Gastrointest Surg 1999;3:583–591.PubMedCrossRefGoogle Scholar
  21. 21.
    Patti MG, Robinson T, Galvani C, Gorodner MV, Fisichella PM, Way LW. Total fundoplication is superior to partial fundoplication even when esophageal peristalsis is weak. J Am Coll Surg 2004;198:863–870.PubMedCrossRefGoogle Scholar
  22. 22.
    Khajanchee YS, Hong D, Hansen PD, Swanstrom LL. Outcomes of antireflux surgery in patients with normal preoperative 24-hour pH test results. Am J Surg 2004;187:599–603.PubMedCrossRefGoogle Scholar
  23. 23.
    Patti MG, Arcerito M, Tamburini A, Diener U, Feo CV, Safadi B, Fisichella P, Way LW. Effect of laparoscopic fundoplication on gastroesophageal reflux disease-induced respiratory symptoms. J Gastrointest Surg 2000;4:143–149.PubMedCrossRefGoogle Scholar
  24. 24.
    Patti MG, Molena D, Fisichella PM, Perretta S, Way LW. Gastroesophageal reflux disease and chest pain. Results of laparoscopic antireflux surgery. Surg Endosc 2002;16:563–566.PubMedCrossRefGoogle Scholar
  25. 25.
    Roman S, Pandolfino JE, Woodland P, Sifrim D. Testing for gastroesophageal reflux in the 21st century. Ann N Y Acad Sci 2011;1232:358–364.PubMedCrossRefGoogle Scholar
  26. 26.
    Mainie I, Tutuian R, Agrawal A, Adams D, Castell DO. Combined multichannel intraluminal impedance-pH monitoring to select patients with persistent gastro-oesophageal reflux for laparoscopic Nissen fundoplication. Br J Surg 2006;93:1483–1487.PubMedCrossRefGoogle Scholar
  27. 27.
    Hirano I, Richter JE, and the Practice Parameters Committee of the American College of Gastroenterology. ACG practice guidelines: esophageal reflux testing. Am J Gastroenterol 2007;102:668–685.PubMedCrossRefGoogle Scholar

Copyright information

© The Society for Surgery of the Alimentary Tract 2012

Authors and Affiliations

  • Brian Bello
    • 1
  • Marco Zoccali
    • 1
  • Roberto Gullo
    • 1
  • Marco E. Allaix
    • 1
  • Fernando A. Herbella
    • 1
  • Arunas Gasparaitis
    • 2
  • Marco G. Patti
    • 1
  1. 1.Department of SurgeryUniversity of Chicago Pritzker School of MedicineChicagoUSA
  2. 2.Department of RadiologyUniversity of Chicago Pritzker School of MedicineChicagoUSA

Personalised recommendations